1. Dale, Barbara A. RN, CHHN, CWOCN

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In 22 years as a home healthcare wound ostomy continence nurse, I have encountered many interesting, and rare wounds. From Pyoderma gangrenosum to Hidradenitis suppurativa and everything in between-but never frostbite. I live in middle Tennessee where average lows range from 31 to 48 degrees, but in late December 2022 an arctic storm brought below zero temperatures and wind chills as low as 30 degrees below zero.

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During this storm, a rural home care patient was concerned about the birds. She put on her coat and went outside. After brushing the snow off the porch railing and laying out some seed for the birds she returned to the house. She was not outside very long with the 3-degree temperature and 25 mile/hour winds, but by late afternoon her fingertips were blistering, and she began experiencing pain. The delayed pain was likely due to diabetic neuropathy. Later that night as the blisters continued to grow and the pain increased, she went to the hospital and was diagnosed with Grade 2 frostbite on all 10 digits. She was prescribed topical Aloe vera gel with 0.5% lidocaine and bacitracin ointment.


When I received the referral 3 days later, I started looking for evidence-based guidelines for frostbite treatment. There are an estimated 200 annual cases of frostbite to the hands in the United States and a total of 488 nationwide for all cases of frostbite with the majority being male and affecting the feet (Zafren & Mechem, 2021). Most of the available information was on prevention of frostbite and first aid, with little information regarding long-term treatment.


The patient had been using Bacitracin but did not have the aloe lidocaine gel. She complained that the dressings were not staying on and she was having to replace them several times a day. I removed the dressings and found that, although all the digits had some degree of frostbite, there were only three areas of full-thickness tissue loss. The wounds were moist but not wet and there were no early signs of infection or cyanosis. The wounds were cleaned, and photos taken. New topical care orders were obtained from her physician to clean and apply a thin layer of Bacitracin covered by a nonadherent and secured by any means possible. I had brought two sizes of stockinette tube bandage with me. We did a makeshift glove but had no thread, string, or yarn to keep the pieces together. I cut strips of gauze and tied each finger sleeve to the main body over the dorsal hand piece. I knew this would not be reusable.


I went home and hand stitched two stockinette gloves that would hopefully hold up for several days and delivered them the next visit. The wounds were improved but I noted some scattered area of maceration on the fingers from tape. While we did the wound care together and placed the new gloves, we talked about frostbite and prevention. Of note, the temperature outside that day was 67 degrees. We talked about possible long-term complications such as paresthesia, arthritis, and joint problems. With the new "gloves" the patient was quite happy and felt she had a lot more ability to use her hands as needed (see photo).


What did we learn about frostbite? Although uncommon in the United States, frostbite can occur in as little as 5 minutes in the right conditions (National Weather Service, 2022). More cases are seen in urban areas related to homelessness rather than in rural areas as with my patient. The damage of frostbite occurs when intense cold causes vasoconstriction with intermittent cycles of vasodilation. Blood is shunted away from the distal areas of the body and freezing of tissues begins. As the tissue freezes, ice crystals can form in cellular spaces and cells, leading to extensive damage to the endothelium of blood vessels (Joshi et al., 2020). With the rewarming process, there is a reperfusion injury cascade that produces prostaglandins, thromboxane, bradykinin, and histamines. This cascade leads to more endothelial injury, decreased blood flow, and potential thrombosis (Sheridan et al., 2022).


Frostbitten skin is usually insensate until rewarming and you can easily further damage tissue. If rewarming outside the clinic setting, make sure the water is no warmer than body temperature. Rewarming is painful and blisters usually develop afterwards. The extent of damage is usually not determined until after rewarming. Although there is high risk for infection, prophylactic antibiotics are not recommended. The recommended topical aloe vera gel and ibuprofen or aspirin are not just for pain relief, they help limit inflammation associated with frostbite by inhibiting thromboxane and prostaglandins in rewarming (Sheridan et al., 2022). The actual tissue damage in frostbite can be thought of in practical terms as somewhere between a burn and an arterial injury. Prevention is key.


The temperature outside in combination with the wind chill is how they calculate if it is going to be 10 minutes or 30 minutes before frostbite can set in (National Weather Service, 2022). Prevention is key.


Most reported substance use among adolescents held steady in 2022

The Monitoring the Future survey is given annually to students in eighth, 10th, and 12th grades who self-report their substance use behaviors. From February through June 2022, investigators collected 31,438 surveys from students enrolled across 308 public and private schools in the United States. Nicotine vaping, illicit drug use, and cannabis and alcohol use remained stable, although alcohol use among 12th graders returned to pre-pandemic levels, with 51.9% of 12th graders reporting alcohol use in the past year. Use of narcotics other than heroin (including Vicodin, OxyContin, Percocet, etc.) increased slightly among 12thgraders between 2021 and 2022 (with 1.7% of 12th graders reporting use within the past year), consistent with the pre-pandemic levels observed in 2019 and 2020 (2.7% and 2.1%, respectively).




Joshi K., Goyary D., Mazumder B., Chattopadhyay P., Chakraborty R., Bhutia Y. D., Karmakar S., Dwivedi S. K. (2020). Frostbite: Current status and advancements in therapeutics. Journal of Thermal Biology, 93, 102716. [Context Link]


National Weather Service (NWS). (2022). Wind chill chart.[Context Link]


Sheridan R. L., Goverman J. M., Walker T. G. (2022). Diagnosis and treatment of frostbite. A review article. New England Journal of Medicine, 386(23), 2213-2220. [Context Link]


Zafren K., Mechem C. C. (2021). Frostbite: Emergency care and prevention.[Context Link]